Levels of health coverage determine the extent to which people are protected from the financial consequences of ill health (financial protection) and have access to needed services. When public resources for health care are limited, policy makers may try to relieve financial pressure by reducing coverage. Coverage has three dimensions:

  • the population covered: 'breadth' or universality
  • the range of services covered: the 'scope' of the benefits package
  • the share of service cost covered: 'depth', whether or not people have to pay user charges for covered services.


By reducing any aspect of publicly financed coverage policy makers are effectively shifting costs to individuals. This creates opportunities for private finance in the form of out-of-pocket payments (including user charges) and voluntary (private) health insurance. Key issues include the extent to which increased reliance on private finance relieves rather than exacerbates financial pressure; strengthens rather than undermines health system performance; and enhances or at least does not lower efficiency in the allocation and use of public resources.

Many of the countries in Europe reported reductions in coverage during the crisis (Mladovsky et al. 2012). Reductions were generally at the margin, mainly affected coverage scope (benefits) and depth (user charges) and were often accompanied by efforts to protect poorer people from higher user charges.

 

Publications

Buescher PA, Head BF, Cassell JW. Recent data on health insurance coverage associated with the economic downturn in North Carolina. N C Med J. 2009 Jul-Aug;70(4):369-71.

Burke S, Thomas S, Barry S, Keegan C. Indicators of health system coverage and activity in Ireland during the economic crisis 2008-2014 - From 'more with less' to 'less with less'. Health Policy. 2014 Sep;117(3):275-8.

Burke SA, Normand C, Barry S, Thomas S. From universal health insurance touniversal healthcare? The shifting health policy landscape in Ireland since theeconomic crisis. Health Policy. 2015 Dec 25 

Carney M. Challenges in healthcare delivery in an economic downturn, in the . J Nurs Manag. 2010 Jul;18(5):509-14.

Castano J, Ospina JE, Caylà JA, Greer SL. Restricting Access to Health Care to Immigrants in Barcelona: A Mixed-Methods Study With Immigrants Who Have Experienced an Infectious Disease. Int J Health Serv. 2016;46(2):241-61.

Cawley J, Moriya AS, Simon K. The impact of the macroeconomy on health insurance coverage: evidence from the great recession. Health Econ. 2013 Nov 14. [Epub ahead of print]

Chang NH, Huang CL, Yang YO. The effects of economic crises on health care. 2010 Aug;57(4):89-94 [Chinese].

Cimas M, Gullon P, Aguilera E, Meyer S, Freire JM, Perez-Gomez B. Healthcare coverage for undocumented migrants in Spain: Regional differences after Royal Decree Law 16/2012. Health Policy. 2016 Feb 17. [Epub ahead of print]

Ferrarini T, Nelson K, Sjöberg O. Unemployment insurance and deteriorating self-rated health in 23 European countries. J Epidemiol Community Health. 2014 Mar 10. [Epub ahead of print] 

Fortes PA, Carvalho RR, Louvison MC. Economic crisis and counter-reform of universal health care systems: Spanish case. Rev Saude Publica. 2015;49:10-2

Fraeyman J, Symons L, De Loof H, De Meyer GR, Remmen R, Beutels P, Van Hal G Medicine price awareness in chronic patients in Belgium. Health Policy. 2014 Dec 8 [Epub ahead of print]

Frischhut M, Levaggi R. Patient mobility in the context of austerity and an enlarged EU: The European Court of Justice's ruling in the Petru Case. Health Policy. 2015 Jul 16. 

Fronstin P. The impact of the 2007-2009 recession on workers' health coverage. EBRI Issue Brief. 2011 Apr;(356):1, 4-19.

Fronstin P. The impact of the recession on employment-based health coverage. EBRI Issue Brief. 2010 May;(342):1-22

Gallo P, Gené-Badia J. Cuts drive health system reforms in Spain. Health Policy. 2013 Aug 17. [Epub ahead of print]

Giovanella L, Stegmüller K. The financial crisis and health care systems in Europe: universal care under threat? Trends in health sector reforms in Germany,  the United Kingdom, and Spain. Cad Saude Publica. 2014 Nov;30(11):2263-2281

Gould E. Employer-sponsored health insurance erosion accelerates in the recession. Int J Health Serv. 2012;42(3):499-537.

Holahan J. The 2007-09 recession and health insurance coverage. Health Aff (Millwood). 2011 Jan;30(1):145-52.

Huang J, Birkenmaier J, Kim Y. Job loss and unmet health care needs in the economic recession: different associations by family income. Am J Public Health. 2014 Nov;104(11):e178-83.

Kentikelenis A. Bailouts, austerity and the erosion of health coverage in Southern Europe and Ireland. Eur J Public Health. 2015 Jun;25(3):365-6. Healthsystems - coverage

Kiernan F, Rahman F. Response to: "Indicators of health system coverage andactivity in Ireland during the economic crisis 2008-2014-From 'more with less' to'less with less"'. Health Policy. 2016 Jan 11.

Kokkinen L, Muntaner C, Kouvonen A, Koskinen A, Varje P, Väänänen A. Welfare state retrenchment and increasing mental health inequality by educational credentials in Finland: a multicohort study. BMJ Open. 2015 Jun 3;5(6):e007297.

Kroneman M, de Jong JD.The basic benefit package: composition and exceptions to the rules. A case study. Health Policy. 2015 Mar;119(3):245-51. Epub 2015 Jan 28.

Lesende IM. Economic crisis and social vulnerability in older people. Aten Primaria. 2014 Jan 16 [Epub ahead of print]

Martin-Moreno JM, Anttila A, von Karsa L, Alfonso-Sanchez JL, Gorgojo L. Cancer screening and health system resilience: keys to protecting and bolstering preventive services during a financial crisis. Eur J Cancer. 2012 Sep;48(14):2212-8.

Mays GP, Hogg RA.Economic Shocks and Public Health Protections in US Metropolitan Areas. Am J Public Health. 2015 Feb 17:e1-e8. [Epub ahead of print]

McKee M, Balabanova D, Basu S, Ricciardi W, Stuckler D. Universal health coverage: a quest for all countries but under threat in some. Value Health. 2013 Jan-Feb;16(1 Suppl):S39-45. 

Milionis C. Provision of healthcare in the context of financial crisis: approaches to the Greek health system and international implications. Nurs Philos. 2013 Jan;14(1):17-27.

Mladovsky P, Srivastava D, Cylus J, et al. Policy summary 5. Health policy responses to the financial crisis in Europe. World Health Organization on behalf of the European Observatory on Health Systems and Policies, 2012

Morrisey MA, Blackburn J, Becker DJ, Sen B, Kilgore ML, Caldwell C, Menachemi N. The Great Recession of 2007-2009 and Public Insurance Coverage for Children in Alabama: Enrollment and Claims Data from 1999-2011. Public Health Rep. 2016 Mar-Apr;131(2):348-56.

Nazarko L, Board M, Garrett D. How might the recession affect acute and community services for older people? Nurs Older People. 2009 May;21(4):16.

O'Flanagan D, Lévy-Bruhl D, Salmaso S. Are European immunisation programmes recession proof? Euro Surveill. 2011 Apr 28;16(17)

O'Toole TP, Buckel L, Redihan S, DeOrsey S, Sullivan D. Staying healthy during hard times: the impact of economic distress on accessing care and chronic disease management. Med Health R I. 2012 Nov;95(11):363-6.

Petrou P. The Ariadne's thread in co-payment, primary health care usage and financial crisis: findings from Cyprus public health care sector. Public Health. 2015 Sep 19. [Epub ahead of print]

Polyzos SA, Kountouras J. Trying to treat diabetes in Greek crisis. Int J Clin Pract. 2012 May;66(5):515.

Poulsen CA. Introducing out-of-pocket payment for General Practice in Denmark: Feasibility and support. Health Policy. 2014 Apr 26.  [Epub ahead of print]

Reeves A, McKee M, Stuckler D. The attack on universal health coverage in Europe: recession, austerity and unmet needs. Eur J Public Health. 2015 Jun;25(3):364-5. 

Royce R. Health coverage lessons from the Greek meltdown. Manag Care. 2013 Jul;22(7):11-2.

Saenz M, Tobler L. Community health centers in the economic downturn. NCSL Legisbrief. 2010 Jan;18(5):1-2

Saltman RB. Health sector solidarity: a core European value but with broadly varying content. Isr J Health Policy Res. 2015;4:5.

Scowen P. Community services and the recession. J Fam Health Care. 2009;19(5):148.

Stefanadis CI. Economic crisis: the role of cardiovascular medicine. Hellenic J Cardiol. 2013 Jan-Feb;54(1):79-80.

Tsounis A, Sarafis P, Alexopoulos EC. Austerity and its consequences on cancer screening in Greece. Lancet. 2014 Dec 13;384(9960):2110

Vargas Bustamante A, Chen J. The Great Recession and Health Spending among Uninsured U.S. Immigrants: Implications for the Affordable Care Act Implementation. Health Serv Res. 2014 Jun 24. [Epub ahead of print]

Vassiliki P, Ioanna K, Artemis V, Eleni K, Aglaia Z, Attilakos A, Maria T, Dimitris K. Determinants of vaccination coverage and adherence to the Greek national immunization program among infants aged 2-24 months at the beginning of the economic crisis (2009-2011). BMC Public Health. 2014 Nov 20;14(1):1192